MATCVS TH ANNUAL SCIENTIFIC MEETING

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Presentation transcript:

MATCVS 2018 19TH ANNUAL SCIENTIFIC MEETING PRE CONGRESS MEETING PERFUSIONIST WORKSHOP 09th AUGUST 2018 SHERATON PETALING JAYA 46200 SELANGOR, MALAYSIA

Topic.. THE SELECTED CASE STUDIES OF INCIDENCE AND ADVERSE EVENTS RELATED TO EXTRACORPOREAL CIRCULATION

Perfusion Safety What AmSECT say??

Malfunctioning or defective equipment and supplies Failure to anticipate adverse events The avoidance of unnecessary incidents that result in adverse patient outcomes Human error or incorrect execution of procedures Communication failure between healthcare professionals

Incident and Adverse Event Well- Known Surveys The first survey entitled “Australasian perfusion incident survey” by Jenkins, Morris and Simpson, was published in Perfusion 1997;12:279-288 The second survey entitled “An update on perfusion safety: does the type of perfusion practice affect the rate of incidents related to cardiopulmonary bypass” by Stammers & Mejak, was published in Perfusion 2001;16:189-198

80% 40% Jenkins, Morris and Simpson, 1997 (0.04%) Stammers and Mejak, 2001 (0.7%)

After 20 years…. Is CPB today safer with a lower risk or do the same incidents occur? If it still happen.. is the frequency different? Are there newer risks associated with new techniques, equipment and procedures?

After 20 years…. But… We can agree that the devices used for CPB today are better and more reliable than in 1990s

Rate

Things To Ponder.. Australian Perfusion Survey 0.04% (1997) US Perfusion Survey 0.7% (2001) Japan Perfusion Survey 1.8% (2013)

Again After 20 years…. Is CPB today safer with a lower risk or do the same incidents occur? If it still happen.. is the frequency different? Are there newer risks associated with new techniques, equipment and procedures?

Again After 20 years…. We still can agree that the devices used for CPB today are better and more reliable than in 1990s But…

After 20 years…. Even with refinements in Perfusion equipment's and techniques as well as increase use of computer assistance and automation, the risk is still unavoidable…

The key ingredient of Perfusion Safety will remain the knowledge and expertise of the Perfusionist

CASE 1 Reference : https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12004331

How to justify/estimates HLM life expectancy?? Wear and Tear issues Technical Support Performance Test Depreciation Spare parts Obsolete

CASE 2

CASE 2

CASE 2

Where is our servo-regulator located at HLM Where is our servo-regulator located at HLM?? Is it safe/risk if any unexpected splash or leaking occur at CPB circuit?? Where is the best place to locate it??

RISK ASSESSMENT What is current status on the towards Perfusion Practice??

A risk assessment is the combination effort of: Identifying and analysing potential events that may negatively impact individuals, assets, and/or the environment (risk analysis) Making judgements on the ‘tolerability of the risk’ after establishing a risk analysis while considering influencing factors (risk evaluation)

Simplifying Risk Assessment… Art of analyses : What can go wrong How likely it is to happen What the potential consequences are How tolerable the identified risk is

CASE 3 The Gritten Report 2007

CASE 3

Take home notes.. The risk assessment is important tools in guiding Perfusionist to anticipate, predict and forecast any significant or non significant risk/hazard Establishment of National Perfusion Practice Standards– collaborations between all parties including MAPS Updating current perfusion protocol Collaboration in training and development

Thank you..